A home health nurse is assessing a patient who has heart failure and notes the patient has had a weight gain of 1.8 kg (4 lb), as well as generalized edema, since the last visit 3 days ago. Which of the following actions should the nurse take next?
Reinforce the importance of daily weights.
Call the health care provider for further instructions.
Document the findings and continue with the visit.
Ensure the client has been taking their prescribed diuretic.
The Correct Answer is D
A. Reinforce the importance of daily weights. While reinforcing the importance of daily weights is crucial for managing heart failure, it does not address the immediate concern of the patient's weight gain and edema. The nurse needs to take a more direct action to manage the patient's current condition.
B. Call the health care provider for further instructions. Calling the health care provider is a reasonable step, but it may delay immediate intervention that the nurse can perform. Ensuring the patient is taking their prescribed diuretic can provide more immediate relief from fluid retention.
C. Document the findings and continue with the visit. Documenting the findings is necessary for accurate medical records, but it does not address the urgent need to manage the patient's symptoms. Immediate action is required to prevent further complications.
D. Ensure the client has been taking their prescribed diuretic. Ensuring the patient has been taking their prescribed diuretic is the most appropriate immediate action. Diuretics help reduce fluid buildup, which can alleviate the weight gain and edema, providing quick relief and preventing further complications.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. This behavior reflects the secretive and recurring nature of binge-purge cycles characteristic of bulimia nervosa. The condition often involves a pattern of eating large amounts of food (binging) followed by compensatory behaviors such as self-induced vomiting (purging) to prevent weight gain.
B. This statement is not characteristic of bulimia nervosa.
C. This statement could indicate laxative abuse, which may occur in individuals with bulimia nervosa, but it is not specific to the disorder.
D. This statement could indicate anorexia nervosa, which is characterized by restrictive eating, but it is not specific to bulimia nervosa.
Correct Answer is D
Explanation
A. Rubbing hands and arms to dry is not a step in the hand hygiene process. After washing, the hands should be dried thoroughly with a clean towel or air dryer.
B. Adjusting the water temperature to feel hot is not necessary for effective hand hygiene. The water should be warm, but not hot, to avoid skin damage.
C. Holding the hands higher than the elbows is not a step in the hand hygiene process.
D. Applying 4 to 5 mL of liquid soap to the hands is the correct amount of soap to use for effective hand hygiene. The soap should be rubbed onto the hands and wrists for at least 20 seconds before rinsing thoroughly with water.
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